Provider Demographics
NPI:1730127309
Name:RUSTIA, JOSE JR (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:RUSTIA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:PO BOX 42934
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101-2934
Mailing Address - Country:US
Mailing Address - Phone:800-355-0808
Mailing Address - Fax:610-834-2862
Practice Address - Street 1:6701 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-6808
Practice Address - Country:US
Practice Address - Phone:443-849-2225
Practice Address - Fax:443-849-3094
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD20246207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDK647A082Medicare PIN
MDD74796Medicare UPIN